Addressing threats to health care's core values, especially those stemming from concentration and abuse of power - and now larger threats to the democracy needed to advance health and welfare. Advocating for accountability, integrity, transparency, honesty and ethics in leadership and governance of health care.
Showing posts with label You heard it here first. Show all posts
Showing posts with label You heard it here first. Show all posts
The Washington Post published just the latest in a growing genre, short-term retrospectives on how the Trump administration horrendously mismanaged the coronavirus pandemic. (See earlier examples here in Vox and here in the New York Times) While no country was able to cruise through the pandemic, and some arguably have done as badly or worse as the United States, our country seemed uniquely positioned to fight a pandemic and lead the world in doing so. We were the richest, spent the most on health care, and had an enviable record - at least prior to the Trump administration - pandemic preparedness.
However, so far we have failed, badly, fatally, and shamefully.
We Warned You
We cannot claim any ability to predict pandemics. We never predicted this one. However, on Health Care Renewal we published warning starting in early 2016 that were Donald J Trump to be elected president of the US, he would prove to be uniquely badly qualified to lead on health care and public health.
No Health Policy, No Health Policy Advisers, Word Salads in Response to Health Care Questions
In February, 2016 we posted that while Trump was then a leading candidate, he had "no health plan" and "no health care policy advisers."
His one major health care proposal at the time was to somehow reduce the cost of drugs by $300 billion. He did not seem to then realize that $300 billion was the then estimated total cost of drug spending. When asked about the mandate provided by the Affordable Care Act his response appeared to be a "word salad." When asked about health policy during a debate, "Mr Trump only seems to have repeated the notion of selling health
insurance across state lines to increase competition, interrupted by non
sequiturs insulting Senator Rubio and insurance executives. The
Minnesota Post writer and I could find absolutely no other content."
My conclusion at the time was:
We live in perilous times when a candidate with such reckless approaches to critical problems continues to attract adulation.
Given this, should it be a surprise that President Trump had no real public health policy, and undermined standard public health approaches to pandemic prevention?
Per the Vox timeline above, as early as on January 22, 2020, Trump said to CNBC
We have it totally under control. It's one person coming in from China, and we have it under control. It's - going to be just fine.
A History of Promoting Health Care Related Scams
In March, 2016, we posted about the Trump Network, a scam that involved the selling of apparently worthless nutritional supplements using equally worthless diagnostic tests.
The basis of the scam was a "network-marketing" (or allegedly "pyramid marketing") scheme in which individuals got monetary incentives not just for selling vitamins and tests, but for recruiting new marketers. In this case, the company sold "nutritional supplements" supposedly custom-designed for each customer based on results of a proprietary urine test. However,
there appeared to be no publicly available data on how the tests worked,
what they actually tested, or how accurate they were. Then there was
no data about how the test results could rationally be used to suggest
particular mixes of vitamin supplements. Also, there was apparently no
public data about what vitamins were in the potions sent to consumers,
their purity, their strength, etc.
Worse, there was no evidence that any of this provided any benefits to the people who ended up taking the vitamins.
Trump bought the company that initially innovated this scheme and rebranded it the Trump Network in 2009. He then enthusiastically marketed its products, and careers marketing them. Marketing videos that include Mr Trump are still readily available online,
In the video, Mr Trump said "Americans need a new plan. They need a new
dream. The Trump Network means to give millions of people a new hope."
Nonetheless, by 2011 the Trump Network was finished.
My conclusions then were:
What damage could such a leader do to health care? And what other
damage could a man who so cavalierly fleeced the little people with his
dubious nutritional product marketing scheme do, especially to the
little people who now so unconditionally support him?
Is there a better example showing why we as a society need to completely
rethink who gets to become our leaders? My only hope is we can do that
rethinking in time to prevent a disaster.
How did that work out for you?
Based on this, is it any surprise that President Trump promoted unproved "cures" for COVID-19 such as hydroxychloroquine; hired "experts" who promoted herd immunity in lieu of a vaccine, which would likely result in millions of deaths were it to be implemented; and even suggested that people should ingest bleach to prevent infection?
According to the Vox timeline, as early as on March 19, 2020, "Trump incorrectly claims that the Food and Drug Administration approved the antimalarial drug hydroxychloroquine for treating Covid-19."
Denying Asbestos-Related Disease, PTSD and Chronic Traumatic Encephalopathy, Asserting Vaccines Cause Autism and Pornography is a Major Public Health Hazard
In November, 2016, just before the election, we posted a catalog of medical/ health care/ public health nonsense that Donald Trump had disseminated.
These included denying that asbestos is an important health hazard; that post-traumatic stress disorder is a manifestation of weakness, not a mental health problem; that chronic traumatic encephalopathy is "a little ding on the head," not a potentially severe neurological condition; and that vaccines cause autism. In addition, the 2016 Republican Party platform that Trump endorsed asserted that pornography is a major public health hazard.
My conclusion at the time was:
It is disturbing when one candidate for the most powerful political
office in the US repeatedly disregards the best clinical and public
health evidence, and offers ill considered opinions about public health
that could potentially harm patients.
Based on this, is it surprising that during a pandemic, President Trump seemed to declare war on biomedical, clinical and public health science, and on professionals who try to implement scientifically based health care and public health?
According to the Vox timeline, as early as on April 17, 2020, "Trump calls on his supporters ... to 'liberate' Michigan, Minnesota, and Virginia...." Those supporters later threatened health care professionals advocated a more scientific approach.
Summary
The history was there. We were warned. We paid a tremendous price. Will we be smarter next time? Will we survive next time?
Introduction: The Coronavirus Pandemic versus Trumpian Denial of Reality
In the absence of a safe and effective vaccine or curative treatments for COVID-19, control of the pandemic rests on collective public action. Public health authorities have been promoting a variety of physical measures that everyone should try to undertake to decrease the spread of the virus.
For example, the US Centers for Disease Control and Prevention (CDC) recommends that everyone should "Wash your hands often.... Avoid close contact ... Stay at least 6 feet (about 2 arms’ length) from other people. Do not gather in groups. Stay out of crowded places and avoid mass gatherings.... Cover your mouth and nose with a cloth face cover when around others." These measures are meant both to protect the people employing them, and those exposed to them.
Many have complied, "flattening of the curve" in some areas, but causing large economic dislocations. Until vaccines or treatments are available, however, it might only be safe to relax the stringency of physical prevention measures if it were possible to quickly diagnose and isolate new cases, and find and isolate their contacts. However, that is not yet possible in most of the US.
Thus it has been disconcerting to see top government leaders publicly spurning the currently recommended physical measures. We recently discussed how the US Vice President excused his failure to wear a mask at a public event by his recent negative test for coronavirus, obtained via his access to a frequent testing regimen at the White House that is far more extensive than anything available to the population. We wondered at the time whether this extraordinary access to testing at the White House may shield the top of the US executive branch from the realities of the epidemic, perhaps partially explaining their less than vigorous response to it.
We also speculated that this extraordinary access was being used by President Trump and associates to promote his propaganda that the pandemic is under control, and use this deception to justify prematurely "reopening" the economy. However, by relaxing prevention measures, this would risk amplifying a still uncontrolled pandemic.
Now media reports suggest that the push to "reopen" is central to the administration's political plans. At the same time, the administration may find that reality can only be denied for so long.
The Maskless Visit to A Mask Manufacturing Facility
In his latest show of support for returning to normal life even as the coronavirus continues to spread, Mr. Trump took a day trip to Phoenix to visit a Honeywell International plant that manufactures N95 masks
Then
In heavily political remarks to Honeywell employees after a tour of the factory, the president said that 'our country is now in the next stage of the battle' against the virus and that 'now we are reopening our country.'
Yet at this mask factory,
Mr. Trump wore safety goggles as he toured the 500-employee plant, which previously manufactured aerospace equipment. But he did not wear a mask, despite signage near the factory floor announcing safety guidelines that included an admonition: 'Please wear your mask at all times.' Other members of Mr. Trump’s entourage, including the White House chief of staff, Mark Meadows, and the national security adviser, Robert C. O’Brien, also did not cover their faces.
The CDC strongly advises every American to wear a mask. The President visits a mask factory, makes political remarks, but he and his entourage fail to wear masks.
At the Honeywell plant that Trump toured, many employees of the company wore masks. Trump’s video showed those employees wearing masks — in fairness, his team didn’t try to hide this — but he and the executives did not wear them, as the video also shows.
It appears this may have been in violation of company policy. CNN’s Jim Acosta tweeted that a sign in the facility said face masks were required.
Furthermore, the article suggested that Trump used his extraordinary access to COVID-19 testing to try to enhance his personal protection to enable this deliberate action. Starting with a statement from Honeywell:
Following White House recommended protocol, a small number of individuals directly interfacing with the President on Tuesday were tested for COVID-19 immediately prior to the event, received negative test results, and were permitted to not wear masks during portions of the visit based on that medical screening. All others present were wearing masks and social distancing in accordance with Honeywell’s site policy.
That strongly suggests the White House initiated this outcome: Honeywell executives, following the White House’s lead, got tested and cleared before interacting with Trump, which they did without masks. Trump aides traveling with him also didn’t wear masks.
Many of the others (such as those in the audience) wore masks, in accordance with Honeywell policy.
That means Honeywell executives might have violated their own company policy, in keeping with what Trump and the White House wanted, obviously for staging purposes.
The article went on to explain the deception involved:
Trump is almost certainly not wearing a mask at such events to send a message to the country that we’re approaching normalcy. That’s likely why Trump and Vice President Pence have been lately holding other events without masks and proper social distancing.
Another reason this matters: As David Nakamura reports, Trump and Pence are able to do this because they have special access to a rapid testing mechanism. Indeed, the White House has defended these mask-free events on precisely that basis.
It’s not surprising that Trump and his entourage have such special testing access, given that he’s president. But this still raises the question of whether Trump is exploiting this access to mislead the country into believing things are normal when the rest of the country lacks this access to testing and thus doesn’t enjoy the safety or quasi-normalcy Trump does.
The article suggests that Trump is using optics to contradict his own administration's policy without saying it in so many words:
'Particularly to his supporters, the behavioral choices he makes carry far more weight than virtually anything else,' Jeremy Konyndyk, a senior fellow at the Center for Global Development, told me. Konyndyk added that even if Trump and those around him benefit from special testing, 'what’s seen by Americans is, 'don’t wear a mask.'
An AP news story on May 7, 2020 also asserted that the goal is to portray a falsely rosy picture of pandemic control:
Trump has told advisers that he believes wearing one would 'send the wrong message,' according to one administration and two campaign officials not authorized to publicly discuss private conversations. The president said doing so would make it seem like he is preoccupied with health instead of focused on reopening the nation’s economy — which his aides believe is the key to his reelection chances.
The AP story also suggested that going maskless is not only meant to visually convey the message is not only that the pandemic is under better control than it actually is, but to appeal to "the Trump base's" ideology and emotions:
While not yet as loaded as a 'Make America Great Again' hat, the mask is increasingly a visual shorthand for the debate pitting those willing to follow health officials’ guidance and cover their faces against those who feel it violates their freedom or buys into a threat they think is overblown.
That resistance is fueled by some of the same people who object to other virus restrictions. The push back has been stoked by President Donald Trump — he didn’t wear a mask during an appearance at a facility making them — and some other Republicans, who have flouted rules and questioned the value of masks. It’s a development that has worried experts as Americans are increasingly returning to public spaces.
'There’s such a strong culture of individualism that, even if it’s going to help protect them, people don’t want the government telling them what to do,' said Linsey Marr, a Virginia Tech engineering professor with experience in airborne transmission of viruses.
At any rate, Trump's push back against the masks the CDC is recommending is propagating among the faithful:
White House aides say the president hasn’t told them not to wear them, but few do. Some Republican allies have asked Trump’s campaign how it would be viewed by the White House if they were spotted wearing a mask.
It appears that President Trump's extraordinary access to health care has not only enabled his lax approach to a lethal pandemic, but has enabled a denial of reality that is influencing people to abandoned social distancing and other such physical prevention measures.
Early in the Trump administration, we noted how the denial of reality had become part of its program:
In 2003 I published an article entitled 'A Cautionary Tale: the Dysfunction of American Health Care,'
which summarized the views of health care professionals about the
causes of health care dysfunction. One of the major findings was the
importance of 'attacks on the scientific basis of medicine.' In turn, I
hypothesized that some of these attacks stemmed from the rise of
post-modernism, then a fashionable intellectual affectation on
university campuses, mainly of the avant garde left-wing. I wrote then:
Postmodernism is 'an attempt to question the fundamental philosophical
and political premises of the West. It argues that many of the
concepts we take for granted—including truth, morality, and
objectivity—are culturally ‘constructed’' To postmodernists, truth is
just what the powerful say is true.
Now it seems that post-modernist 'thought' has escaped the confines of
left-wing humanities departments, and infiltrated political discourse,
and for some unfathomable reason, seems to particularly affect some of
those who profess to be conservative. After all, in January, KellyAnne
Conway, a senior White House adviser, defended the administration's
arguments as 'alternative facts.' (Look here.)
Now the reality of extraordinary access to health care has given Trump a tool to make "alternative facts" seem so real that his followers act on them.
Denying Reality May Not Prevent its Intrusion
Of course, in the real world, reduction in physical prevention measures
in the continuing absence of safe and effective vaccines or treatments
likely will cause an amplification of the pandemic, and hence more
disease, more death, and more health care facilities at risk of
collapse. Those who are influenced by Trump's propaganda would not be
immune to these dangers. Neither would the people with whom they have
contact, including their friends and family.
Reality often strikes back at those who deny. In this case, reality may be striking back quickly. The same day after the AP story above was published, and immediately after I wrote most of the post above, CNN reported that coronavirus had invaded the White House:
A member of the US Navy who serves as one of President Donald Trump's personal valets has tested positive for coronavirus, CNN learned Thursday, raising concerns about the President's possible exposure to the virus.
The valets are members of an elite military unit dedicated to the White House and often work very close to the President and first family.
The infected staffer is one of Trump’s personal valets, the military staff members who sometimes serve meals and look after personal needs of the president. That would mean the president, Secret Service personnel and senior members of the White House staff could have had close or prolonged contact with the aide before the illness was diagnosed.
The report also clarified that there was little observance of physical prevention measures in the White House.
the president likes to meet with many people and is itching to travel more, these aides said.
Nonetheless,
wider use of masks among staffers close to Trump is expected but will remain optional.
Relatively few staffers who interact frequently with the president wear masks. One who did, deputy national security adviser Matthew Pottinger, drew snickers from his colleagues, according to aides.
Trump has never worn a face mask in public during the pandemic and has said that to do so while performing his official duties would be unseemly.
Furthermore,
Junior staffers often wear masks, but senior-level officials who meet with Trump have generally not worn them, three White House officials said.
Several former White House personnel said they have asked previous colleagues still working at the White House why staff members on the grounds, and especially those in proximity to Trump, were not automatically following a protocol of wearing masks and being regularly tested before this point.
'The president sees it as a sign of weakness to wear masks and so people just haven’t been doing it,' one current employee responded, according to a person familiar with that conversation.
One day later (May 8, 2020), reports of a second White House staffer with coronavirus appeared. This time, the staffer was political, not a member of the military assigned to the White House, and one particularly likely to have been in close contact with the top levels of political leadership. Per NPR,
The White House on Friday confirmed a second case of coronavirus this week, now in Vice President Pence's office, as both the president and his No. 2 have recently begun traveling again.
Pence spokeswoman Katie Miller tested positive for the virus on Friday, after having tested negative Thursday.
Note that
Miller is married to Trump senior adviser Stephen Miller, whose fiery anti-immigration stance and public loyalty to the president has made him one of Trump's closest allies.
Miller is married to Stephen Miller, a senior adviser to Trump who has interacted with him this week, though it remained unclear late Friday whether the couple would both be quarantined at home. The White House said Pence tested negative for the virus as did the aides removed from his plane.
Yet Katie Miller’s positive test raised questions over who else she might have been in contact with. She has attended nearly all of the White House coronavirus task force meetings, led by Pence, in the Situation Room, aides said.So
Here is the double-bind produced by post-modernist reality denial. Now Trump et al either must accept the reality of the pandemic, or assume a real personal risk of being infected, possibly getting very sick, and possibly dying. As the Washington Post, May 8, put it:
'This is a show of bravado. This is a show of ‘I got this. I’m in control,’ ' said one former security official familiar with White House security planning during past administrations.
'He’s tried to minimize this threat from day one. It’s the only way he can laugh in the face of this disease,' said this person, who like others spoke on the condition of anonymity to frankly address sensitive security matters. “If he backtracks now, and starts wearing a mask, it will contradict the red meat he’s feeding to his base constantly. This is the first health crisis that has been politicized.'
In the bad old days when post-modernism was rampant on university
campuses, I suspected that the post-modernists denied reality only as
part of a cynical academic pose. I went to a talk by a post-modernist academic who denied the existence of a single external
reality. Later I heard her take part in an intensely practical conversation about travel options at the
post-talk social hour. I sidled into the conversation and asked if there is no reality, why don't you fall through the apparent but unreal floor into the depths of the earth? She
smiled nervously and found someone else to talk to. I suspect no
academic post-modernist had sufficient belief in their intellectual
position that they would walk in front of an oncoming bus because it was not part of external reality.
So if Trump et al are like the old academic post-modernists, they would quickly start social distancing and physical measures to mitigate the pandemic at the White House. However, maybe they would have to stop laughing at the coronavirus and pay some heed to the need to competently manage the pandemic.
However, at the time I am writing this, I am not sure Trump et al will not step in front of the bus. From the Washington Post, May 8:
President Trump on Friday continued to eschew key public health guidelines from his own administration — meeting with Republican lawmakers and World War II veterans without a face mask — while expressing confidence that he is protected from the coronavirus despite a second White House staffer testing positive this week.
Furthermore,
On Thursday, the president met with close advisers, including son-in-law Jared Kushner, Republican National Committee Chairwoman Ronna McDaniel and campaign manager Brad Parscale, who brought with him five prototype masks featuring the Trump-Pence reelection logo.
Trump was delighted with the campaign swag and approved its distribution for public sale, officials said, and Parscale posted a photo on Twitter of himself wearing the mask.
But that was the only time anyone involved in the meeting had worn any sort of face covering, the officials said.
Three visitors to the White House on Thursday said that few officials inside the complex were wearing masks, and Trump and senior aides did not bring up the positive tests or express safety concerns.
As Trump often says, "we will see what happens."
At least if the Trump does figuratively walk in front of the bus, he and his associates may not be around to laugh at the coronavirus much longer, and there would be a
chance the rest of us could leap out of the bus' way on our own before its too late.
Conclusion
As we wrote in 2017:
Facts ... are stubborn things. Evidence is evidence, no matter
what politician it might offend. Basing legislation [or action] on the sorts of
alternative thinking displayed in the cases above could lead to real
life, or life and death consequences for the sick, injured and
vulnerable. True health care reform requires clear thinking and the
input of people who actually know something about health care.
In last night's debate which included leading candidates from the Democratic Party for its presidential nomination, as reported by Mother Jones, Senator Bernie Sander (D-VT) said (per Mother Jones).
the current health care system is not only cruel, it is dysfunctional
The video is here.
So the concept of health care dysfunction has officially made it to the big time.
You Heard It Here First
What took so long?
We have been talking about health care dysfunction for a very long time, starting with a publication in 2003.
To better understand health care dysfunction, I interviewed doctors and health
professionals, and published the results in Poses RM. A cautionary
tale: the dysfunction of American health care. Eur J Int Med 2003; 14(2): 123-130. (link here).
In that article, I postulated that US physicians were demoralized
because their core values were under threat, and identified five concerns:
1. domination of large organizations which do not honor these core values
2. conflicts between competing interests and demands
3. perverse incentives
4. ill-informed, incompetent, self-interested, conflicted or even corrupt leadership
5. attacks on the scientific basis of medicine, including manipulation and suppression of clinical research stuides
After that my colleagues and I have
tried to raise awareness of these and related issues, now mainly
through the Health Care Renewal blog. We also set up FIRM - the Foundation for Integrity and Responsibility
in Medicine, a US non-profit organization, to try to
provide some financial support for the blog.
Health Care Dysfunction is Multi-Dimensional
Unfortunately, one sentence in a presidential debate hardly does justice to a huge and multi-faceted set of concerns.
Since 2003 we have broadened our thinking about what constitutes and causes US (and more global) health care dysfunction. Early on we noticed a number of factors that seemed to enable increasing
dysfunction, but were not much discussed. These factors notably
distorted how medical and health care decisions were made, leading to
overuse of excessively expensive tests and treatments that provided
minimal or no benefits to outweigh their harms. The more we looked, the more complex this web of bad influences seemed. Furthermore, some aspects of it seemed to grow in scope during the Trump administration.
A brisk summary of these often complex issues follows.
Threats to the Integrity of the Clinical Evidence Base
The clinical evidence has been increasingly affected by manipulation
of research studies. Such manipulation may benefit research sponsors, now
often corporations who seek to sell products like drugs and devices and
health care services. Manipulation may be more likely when research is
done by for-profit contract research organizations
(CROs). When research manipulation failed to produce
results to sponsors' liking, research studies could simply be suppressed or hidden.
The distorted research that was thus selectively produced was further
enhanced by biased research dissemination, including ghost-written
articles ghost-managed by for-profit medical education and
communications companies (MECCs). Furthermore, manipulation and
suppression of clinical research may be facilitated by health care
professionals and academics conflicted by financial ties to research sponsors.
Deceptive Marketing
The distorted evidence base was an ingredient that proved useful in deceptivemarketing of health care products and services. Stealth marketing
campaigns became ultimate examples of decpetive marketing. Deceptive
marketing was further enabled by the use of health care professionals
paid as marketers by health care corporations, but disguised as unbiased
key opinion leaders, another example of the perils of deliberate generation of conflicts of interest affecting health care professionals and academics.
Distortion of Health Care Regulation and Policy Making
More recently, as we noted here, we became aware of efforts by foreign powers to spread such disinformation for political, not just financial gain, e.g., in April, 2019,
we discussed evidence that Russia had orchestrated a systemic
disinformation campaign meant to discredit childhood vaccinations,
particularly for the measles, which was likely partly responsible for
the 2019 measles outbreak
Furthermore, companies selling health care products and services further enhanced their positions through regulatory capture,
that is, through their excessive influence on government regulators and
law enforcement. Their efforts to skew policy were additionally
enabled by the revolving door,
a species of conflict of interest in which people freely transitioned
between health care corporate and government leadership positions.
In the Trump era, we saw a remarkable increase in the incoming revolving
door, people with significant leadership positions in health care
corporations or related groups attaining leadership positions in
government agencies whose regulations or policies could affect their
former employers (look here). We found multiple managers from and lobbyists for big health care
corporations being put in charge of regulation of and policy affecting -
wait for it - big health care corporations, a staggering
intensification of the problem of the revolving door.
Bad Leadership and Governance
Health care leadership was often ill-informed.
More and more people leading non-profit, for-profit and government have
had no training or experience in actually caring for patients, or in
biomedical, clinical or public health research. Lately, during the Trump administration, we began to find striking examples of top government officials expressing ill-informed,
if not outright ignorant opinions about medical, health care and public
health topics look here). We had not previously expected leaders of government to
be personally knowledgeable about health related topics, but
traditionally they consulted with experts before making pronouncements.
Health care leaders often were unfamiliar with, unsympathetic to, or frankly hostile to their organizations' health care mission, and/or health care
professionals' values. Often business trained leaders put short-term revenue ahead of patients' or the public's health. In addition, we began to see evidence that leaders of health care corporations were
using their power for partisan purposes, perhaps favoring their personal
political beliefs over their stated corporate missions, patients' and
the public's health, and even corporate revenues. Then, we started seeing appointed government health care leaders who lacked medical, health care or public health background
or expertise but also whose agenda also seemed to be overtly religious or
ideological, without even a nod to patients' or the public' health (look here).
Leaders of health care organizations increasingly have conflicts of interest. Moreover, we have found numerous examples of frank corruption of health care leadership. Some have resulted in legal cases involving charges of bribery, kickbacks, or fraud. Some have resulted in criminal convictions,
albeit usually of corporate entities, not individuals.
In the Trump administration, corrupt leadership extends from the corporate world to the highest levels of the US government. We discussed the voluminous reports of conflicts of interest and corruption affecting top leaders in the executive branch, up to and including the president and his family (look here). One cannot expect effective enforcement of ethics rules and anti-corruption laws in such an environment
Abandonment of Health Care as a Calling
A US Supreme Court decision was interpreted to mean that
medical societies could no longer regulate the ethics of their members,
leading to the abandonment of traditional prohibitions on the commercial
practice of medicine.
Until 1980, the US American Medical Association had ruled that the
practice of medicine should not be "commercialized, nor treated as a
commodity in trade." After then, it ceased trying to maintain this
prohibition. Doctors were pushed to be businesspeople, and to give
making money the same priority as upholding their oaths. Meanwhile, hospitals and other organizations that provide medical care are increasingly run as for-profit organizations. The physicians and
other health care professionals they hire are thus providing care as
corporate employees, resulting in the rise of the corporate physician. These health care professionals may befurther torn between their oaths, and the dictates of their corporate managers.
We have extensively discussed the perverse incentives
that seem to rule the leaders of health care. Financial incentives may
be large enough to make leaders of health care organizations rich. Incentives often prioritize financial results over patient care. Some
seem to originate from the shareholder value dogma promoted in business
school, which de
facto translates into putting current revenue ahead of all other
considerations, including patient care, education and research (look here).
Cult of Leadership
Health care CEOs tend
now to be regarded as exalted beings, blessed with brilliance, if not
true "visionaries," deserving of ever increasing pay whatever their
organizations' performance. This pheonomenon has been termed "CEO disease" (see this post).
Afflicted leaders tend to be protected from reality by their
sycophantic subordinates, and thus to believe their own propaganda.
Leadership of health care organizations by managers with no
background in actual health care, public health, or biomedical
science has been promoted by the doctrine of managerialism which
holds that general management training is sufficient for leaders of all
organizations, regardless of their knowledge of the organizations'
fundamental mission.
Most cases involving corruption in large health care organizations are resolved by legal settlements.
Such settlements may include fines paid by the corporations, but not by
any individuals. Such fines are usually small compared to the revenue
generated by the corrupt behavior, and may be regarded as costs of doing
business. Sometimes the organizations have to sign deferred prosecution or corporate integrity agreements. The former were originally meant to give young, non-violent first offenders a second chance (look here). However, in most instances in which corruption became public, are no negative
consequences ensue for the leaders of the organizations on whose watch
corrupt behavior occurred, or who may have enabled, authorized, or
directed the behaviors.
Taboos
Some of the above topics rarely appeaedr in the media
or scholarly literature, and certainly seem to appear much less
frequently than their importance would warrant. We have termed the failure of such issues to create any echoes of public discussion the anechoic effect.
Public discussion of the issues above might discomfit those who
personally profit from the status quo in health care. Those involved in the leadership
and governance of health care organizations and their cronies, also have
considerable power to damp down any public discussion that might cause
them displeasure. In particular, we have seen how those who attempt to blow the whistle on what really causes health care dysfunction may be persecuted.
However,in the Trump administration, we began to also note examples of government officials attempting to squelch discussion of scientific topics that did not fit
in with its ideology, despite constitutional guarantees of speech and
press free from government control (look here).
What a witches' brew, surely leading to a cruel and dysfunctional system.
Discussion
In 2017, we said that it was time to consider some of the real causes of health care dysfunction that
true health care reform needs to address, no matter how much that
distresses those who currently most personally profit from the status
quo.
Furthermore, in 2019 we asserted that all the trends we have seen since 2017 are towards tremendous government dysfunction, some of it overtly
malignant, and much of it likely enabling even worse health care dysfunction.
Now that health care dysfunction is in the headlines, we hope health care and public health professionals, patients, and all citizens
will have a much more vigorous response to it. US health care dysfunction was
always part of the broader political economy, which is now troubled in
new and dangerous ways. We do not have much time to act.
If not now, when?
If not us, who?
Note (25 November, 2019): This post was re-posted by the Naked Capitalism blog here.
The Food and Drug Administration said on Friday that it had detected low levels of a cancer-causing contaminant in samples of heartburn medicines containing the drug commonly known as Zantac.
Zantac, the brand-name version of the drug, is sold by Sanofi, but generic versions [ranitidine] are widely sold. The F.D.A. has not identified any specific products that were affected.
The contaminant is one that has been seen before.
The contaminant, a type of nitrosamine called N-nitrosodimethylamine, or NDMA, is the same one that was found in some versions of valsartan, a blood-pressure drug carrying the brand name Diovan.
In the current case, its source is not yet apparent,
NDMA can form during manufacturing if the chemical reactions used to make the drug are not carefully controlled and monitored, the F.D.A. has said.
Jeremy Kahn, an agency spokesman, said Friday that the agency is still investigating contamination of the heartburn drugs, and that it is unclear how many companies’ products are affected and how the problem originated.
Based on the recent case of adulterated valsartan and other angiotensin receptor blocker (ARB) drugs, tt is likely that manufacturing of the drug, at least the "active pharmaceutical ingredient" in it, was outsourced.
The valsartan recalls have renewed questions about the safety of the American drug supply, particularly of generic drugs, composed of raw ingredients that are frequently manufactured in countries like China and where F.D.A. oversight has lagged.
Note that,
The source of the contaminated valsartan was a Chinese manufacturer, Zhejiang Huahai Pharmaceutical Company. Major Pharmaceuticals, Teva Pharmaceutical Industries and Solco Healthcare, which is owned by Huahai Pharmaceutical, sold it in the United States.
The same type of impurities were later found in two other blood-pressure drugs, irbesartan and losartan, in the same [ARB] class as valsartan. Two more nitrosamines — nitrosodiethylamine, or NDEA, and N-Nitroso-N-methyl-4-aminobutyric acid, or NMBA — were found in the drugs. Lists of the affected products are posted on the F.D.A. website.
Furthermore, the FDA may not yet be on top of the problem with ranitidine:
The agency’s announcement came on the same day that an online pharmacy, Valisure, petitioned the F.D.A. to request a recall of all products containing ranitidine, because it said its own tests had revealed high levels of NDMA, above the F.D.A.’s acceptable daily limit. The Valisure petition speculated that the source of the NDMA was the result of the 'inherent instability' of the ranitidine molecule, which can degrade under certain conditions, such as when it is digested, to create NDMA.
'Our feeling is that this is extremely troublesome,' said David Light, the chief executive of Valisure, which is based in Connecticut. 'We took it off our formulary right away.'
21st Century Cases of Drug Adulteration
Moreover, we should have been warned that these cases were coming.
The cases of adulterated ranitidine and ARBs are not the first important
cases of drug adulteration in the 21st century. In 2008, we wrote aabout
the case of toxic adulterated heparin from pigs in China. We later summarized of that case was:
Baxter International imported the 'active pharmaceutical ingredient'
(API) of heparin, that is, in plainer language, the drug itself, from
China. That API was then sold, with some minor processing, as a Baxter
International product with a Baxter International label. The drug came
from a sketchy supply chain that Baxter did not directly supervise,
apparently originating in small 'workshops' operating under primitive
and unsanitary conditions without any meaningful inspection or
supervision by the company, the Chinese government, or the FDA. The
heparin proved to have been adulterated with over-sulfated chondroitin
sulfate (OSCS), and many patients who received got seriously ill or
died. While there have been investigations of how the adulteration
adversely affected patients, to date, there have been no publicly
reported investigations of how the OSCS got into the heparin, and who
should have been responsible for overseeing the purity and safety of the
product. Despite the facts that clearly patients died from receiving
this adulterated drug, no individual has yet suffered any negative
consequence for what amounted to poisoning of patients with a brand-name
but adulterated pharmaceutical product.
In 2010, we noted a report by the U.S. China Economic and Security Review Commission on the perils of outsourced drug manufacturing in China.
In 2012 we documented
the continuing problems with outsourcing of drug manufacturing. We
noted that at least 70-80% of the "active pharmaceutical ingredients"
(APIs) that made up drugs sold in the US were actually manufactured
overseas, the majority in China and India. The regulation of
manufacturing in these countries, particularly China, is extremely lax.
In China, APIs are considered chemicals, and the regulation of chemical
manufacture is virtually non-existent. There is evidence that the
manufacturing processes in China, particularly at those companies that
make the cheapest drugs, are sloppy or worse. Furthermore, US
pharmaceutical companies may buy drugs through brokers, further
obscuring who actually made them.
In 2013, we discussed adulteration of generic drugs made in India by Ranbaxy, a subsidiary of Daiichi Sankyo, and sold in the US.
Summary: Broken Trust
The latest cases of adulterated drugs sold in the US are disgraceful. Patients ought to be assured that the medications they take have not been adulterated. Patients entrust pharmaceutical corporations to supply pure drugs in the correct dosage. The purpose of the first major US law to regulate drugs, the US Food and Drug Act of 1906, was to assure that drugs were pure and their dosage was accurate. The presence of adulterated drugs on pharmacy shelves is a major breach of trust, and shows a major failing of the involved pharmaceutical manufacturers and US drug regulation.
If anything, the NYT article understates the problem,
'I think this is another good example of how our regulations need to
change,' said Dinesh Thakur, a drug-safety advocate who exposed
widespread quality problems as a former executive at the Indian drug
maker Ranbaxy Laboratories. He said the F.D.A.’s testing is too lax.
'Things like this will never get caught, unless somebody is actually
actively looking for stuff.'
Since 2008 we have had warnings that outsourced drugs may be dangerous, and that foreign and US regulation is insufficient. Yet, the warning have largely been anechoic and no major action has ensued. Will the new cases make waves? Will there be action this time? Who knows?
For what it's worth, let me resurrect my thoughts from 2016:
In our rush to market fundamentalism, we seem to have deregulated, at
least de facto, most aspects of health care. We now cannot trust the
drugs we take to have been made by the companies whose labels they bear,
or to be pure. We now cannot trust that regulators will find that out,
or having found that out, will do anything about it in a timely
manner.
To repeatedly reiterate, as long as the leaders of health care
organizations are not held accountable for the results of their
decisions on health care quality, cost, and access (even in such extreme
quality violations as those resulting in multiple patient deaths), we
can expect continuing decisions that sacrifice quality, increase costs,
and worsen access, but that are in the self-interest of the people
making them.
To really reform health care, we must hold health care organizations and
their leaders accountable (and not blame all the problems on doctors,
other health care professionals, patients, and society at large).
In 2017, we noted that President Trump had appointed a member of his Council of Economic Advisers who previously was a master corporate stealth health policy advocate. Now he is getting a promotion.
Prof Tomas Philipson to be Named to Chair of the President's Council of Economic Advisers
President Trump plans to name economist Tomas Philipson as the next head of the White House Council of Economic Advisers, according to senior administration officials.
Philipson has worked at the White House for nearly two years as a senior economist after serving briefly on the transition team. Best known for his research on health care, Philipson has been a key player in the Trump administration’s efforts to lower drug prices and push back against Democrats’ proposals for a Medicare-for-all system.
The Post noted that during his tenure on the Council it released a report warning of the financial dangers of proposals for a national single payer health insurance system ("Medicare for all"), which is labelled "socialism."
Also, it quoted him as saying
Deregulation is the cornerstone of the president’s pro-growth economic policies that has been implemented since he took office,
The article also briefly described his "long career and academia and public service."
'Tom is a very fresh thinker,' said Mark McClellan, a veteran of the George W. Bush administration who recruited Philipson to work for him, first at the FDA and later at the Centers for Medicare & Medicaid Services. 'Tom had a great background in health economics and wanted to do work that was very policy relevant. So it was a win-win.'
A health economist as the chief White House economic adviser sounds like a good idea on its face, but the reality is much more complex.
Philipson's Career as a Master Stealth Health Policy Advocate
In February, 2017, months before Philipson ascended to the Council, a ProPublica article noted that Philipson was "the third co-founder of Precision Health Economics" (PHE).
As we said later in 2017, PHE was in the business of using its experts' academic credentials to help pharmaceutical and biotechnology companies influence public policy in their favor. From the ProPublica article
Over the last three years, pharmaceutical companies have mounted a public relations blitz to tout new cures for the hepatitis C virus and persuade insurers, including government programs such as Medicare and Medicaid, to cover the costs.
So,
To persuade payers and the public, the industry has deployed a potent new ally, a company whose marquee figures are leading economists and health care experts at the nation’s top universities. The company, Precision Health Economics, consults for three leading makers of new hepatitis C treatments: Gilead, Bristol-Myers Squibb, and AbbVie.
Furthermore,
This is just an extension of the way that the drug industry has been involved in every phase of medical education and medical research,' said Harvard Medical School professor Eric G. Campbell, who studies medical conflicts of interest. 'They are using this group of economists it appears to provide data in high-profile journals to have a positive impact on policy.'
PHE has worked with some of the biggest pharmaceutical and biotechnology companies and trade groups. In particular,
ProPublica described some of the tactics PHE uses:
The firm participates in many aspects of a drug’s launch, both advising on 'pricing strategies' and then demonstrating the value of a drug once it comes on the market, according to its brochure. 'Led by professors at elite research universities,' the group boasts of a range of valuable services it has delivered to clients, including generating 'academic publications in the world’s leading research journals” and helping to lead “formal public debates in prestigious, closely watched forums.'
PHE has worked on campaigns to persuade the government and insurers to increase what they would pay for oncology drugs, and for Amgen's PCSK9 inhibitor (Repatha) for hypercholesterolemia.
Tomas Philipson was one of the principals of PHE:
Precision
Health Economics may be well-positioned to influence the Trump
administration. Tomas Philipson, an economist at the University of
Chicago and the third co-founder of Precision Health Economics,
reportedly served briefly as a senior health care adviser for the Trump
transition team. He did not respond to requests for comment.
He has taken an active role in stealth health policy advocacy campaigns run by PHE. For example, as part of the PHE campaign to advocate for generous government and commercial insurance payments for Repatha, Philipson disparaged an analysis by the Institute of Clinical and Economic Review which had suggested the drug was overpriced:
Philipson, the Precision Health Economics co-founder, and Jena wrote an op-ed in Forbes, citing the institute’s research and deriding its approach to value pricing as 'pseudo-science and voodoo economics.'
PHE and its principals, including Philipson, often failed to disclose relevant conflicts of interest. For example, re the above Forbes article,
Only Philipson disclosed his ties to Precision Health Economics, and neither academic disclosed that Amgen was a client of the firm.
Failing to disclose the Amgen funding of their work in this context appeared deceptive.
Up to the time of his appointment to the Council of Economic Advisers, Philipson seemed to be enhancing his position at PHE. In particular, in 2015, after PHE was bought out by a privately held biotechnology company, "Philipson ... [was] listed as chief economist and the chair of the strategy and innovation board."
However, Philipson's previous work on stealth advocacy campaigns for pharmaceutical and biotechnology companies did not prevent him from becoming a member of the Council of Economic Advisers. Now that Philipson is likely to ascend to the chair of the Council, Philipson's previous record of stealth health policy advocacy has been anechoic.
Summary and Conclusions
The anechoic nature of this latest case shows how we are becoming
numb to many common abuses in health care in the face of even worse abuses in the larger political economy, the ultimate
defining down of deviancy.
Nonetheless, let me first emphasize that Philipson came through the revolving door from his role as a stealth health policy advocate to become a major Trump regime economic adviser.
The literature makes clear that the revolving door process is a source of valuable political connections for private firms. But it generates corruption risks and has strong distortionary effects on the economy, especially when this power is concentrated within a few firms.
In the Trump era, many people have come through the incoming revolving
door, that is, people with significant leadership positions in health care
corporations or related groups have attained leadership positions in
government agencies whose regulations or policies could affect their
former employers. Many examples, starting with Philipson's initial appointment to the Council, appeared here. The more people transit the revolving door from the world of big corporations to government, the more government appears rigged to do the bidding of big corporations and their munificently paid leaders.
Philipson is not merely an adviser to pharmaceutical and biotechnology companies. He was an active participant and innovator in stealth health policy advocacy (or maybe stealth lobbying.) Putting an innovator in stealth health policy advocacy and lobbying in the top economic position in the White House will only amp up the power of propagandists and disinformation purveyors in government.
Meanwhile, top health care (and other) corporate
management is increasingly merging with the current administration in
one giant corporatist entity which is not in the interests of health care. To derig the system, we need wholesale, real health care
reform that would make health care
leaders accountable for what their organizations do, and would cut the ties between
government and corporate leaders and their cronies that have lead to government of, for
and by corporate executives rather than the people at large.
However, before thinking about true health care reform, we need top accomplish wholesale government reform. We need to excise the deception, crime and corruption at the heart of our government and restore government by the people, of the people, and for the people.
Hahnemann University Hospital will close in early September, with the wind-down of services at the 496-bed facility starting immediately, hospital officials said Wednesday.
Officials representing American Academic Health System LLC, which bought Hahnemann and St. Christopher’s Hospital for Children early last year for $170 million, said the closing 'on or about Sept. 6' would be orderly.
The closure would likely have big impacts on health care and medical education in Philadelphia, and on health care professionals and other hospital workers. The article quoted the president of the Pennsylvania Association of Satff Nurses and Allied Professionals:
Hahnemann is a safety-net hospital that for decades has provided care to an under-served community,
Hahnemann University Hospital’s pending closure and immediate move to turn away critically ill emergency patients threatens a safety net that has served close to 150 emergency room patients a day — many of them poor minorities who rely on the hospital for even primary care.
Close to half of the people admitted to Hahnemann were on Medicaid and two-thirds are black or Latino, according to an Inquirer analysis of state inpatient billing data.
Also,
Hahnemann had 17,000 inpatient stays and 53,000 emergency room visits in 2017, making it the eighth-busiest E.R. in the city, according to state Department of Health statistics.
The plight of the hospital's current house staff got a bit more attention. An Inquirer article on July 3, stated,
The impending closure of Hahnemann University Hospital is forcing about 570 residents who work at the Center City institution to find a new place to continue their training.
Also,
Hahnemann’s closure is causing 'the largest orphaning of medical residents in the history of the United States,' Drexel University said in a Philadelphia Court of Common Pleas lawsuit against Hahnemann and its corporate parents. Drexel handles the educational side of Hahnemann’s residency programs.
The closure would leave around 800 union nurses, said the union, which represents around 8,500 nurses across the state.
In addition,
The nurses are among about 2,500 employees that PAHS says are employed at the medical center.
A major teaching hospital will close, abandoning many poor and vulnerable patients, orphaning 570 house-staff and leaving about 800 nurses and about 1700 other staff unemployed, and the national media take no notice? The numbness is striking.
Reactions to the Bankruptcy of Hahnemann
Also, in my humble opinion, the reactions to the impending bankruptcy were somewhat muted even in the local media.
The media did feature some complacent reactions from local health care experts with ties to other competing hospital systems or to for-profit hospital management who seemed confident that everything would work out. For example, from the June 26 Inquirer article:
But
with more hospital beds per capita than many urban areas, Philadelphia
is better equipped to handle the impact of a closure than many places,
said Stuart H. Fine, an associate professor in Temple University’s
College of Public Health.
'Philadelphia is fortunate to
have enough hospital beds for the city’s needs, even if Hahnemann
closes,' he said. 'I’m not minimizing the impact of this closure on
those patients who live right by Hahnemann, rely upon it for their care,
and will have difficulty traveling to other locations.'
The article, though, failed to mention that Mr Fine, per his bio on the Temple website, is a former hospital manager with a health administration, but not a public health or medical background, viz:
After
having served as a health system CEO for more than 30 years, Dr. Stuart
H. Fine joined the faculty of Temple University in 2014 as Associate
Professor & Director of Programs in Healthcare Management for
the Fox School of Business.
A few public relations
people from other local hospitals seemed pleased about getting some of
Hahnemann's business, but I could find no opinions from actual public
health experts.
On the other hand, there was outrage from unionized employees (look here for an account of a small public protest by union members.)
The Governor of Pennsylvania and the Mayor of Philadelphia, both Democrats, issued a statement saying
We continue to stand in solidarity with the workers, patients and community. For months, the commonwealth and city have been working aggressively to protect patient care at Hahnemann and find solutions to maintain current medical services at the hospital,
However, they did not propose very strong action
While it is clear that the hospital’s current operation is no longer financially viable, we are both committed to working with potential investors to find support for the restructuring of Hahnemann and for protecting St. Christopher’s Hospital for Children
Note that they did not seem to question the notion that any continuation of Hahnemann would have to be as a for-profit corporate entity funded by "investors."
The American Association of Medical Colleges put an informational article on its website, featuring an interview with Janis Orlowski, MD, AAMC chief health care officer. However, the article only discussed the nuts and bolts of how Hahnemann housestaff might go about trying to find new positions. There was no hint of outrage, and nothing about anything the AAMC might do beyond that.
The only discussion about the bankruptcy beyond the Philadelphia area that I could find came from presidential candidate Sen Bernie Sanders (D-VT), who was quoted in Politco a few days after the bankruptcy announcement:
'The business model of America’s current health care system is not about healing people or providing access to medical care — it is about making as much money as possible for insurance companies, drug companies and wealthy investors,' the Democratic presidential candidate said.
'The situation in Philadelphia illustrates the entire problem: In a city with one of the highest poverty rates in the country, a major hospital serving low-income communities is on the verge of laying off 2,500 people, abandoning 500 medical residents, and closing its operations thanks to an investment firm looking to make as much money as possible in a corporate fire sale.'
The Vermont senator added that he stood in solidarity with the nurses and others who are fighting to keep the hospital 'from being destroyed by Joel Freedman and his investment firm' and reiterated his call for 'Medicare for All.'
Per the Inquirer, again, Sen Sanders is also planning a rally for July 15, and plans "to call for Philadelphia, state and federal officials to find a way to keep Hahnemann open."
A major teaching hospital will close, abandoning many poor and
vulnerable patients, orphaning 570 house-staff and leaving about 800
nurses and about 1700 other staff unemployed, and there is no national outrage, particularly from health care professionals? The learned helplessness is striking.
Finally, lacking in what reporting there has been, however, is much
explanation for why a big teaching hospital is coming to such a sudden,
and ignominous end, particularly, since in a sense it has all been done
before. One gets the impression of deep seated ennui.
A Very Late Echo of the Fall of the House of AHERF
There might be a reason for that. It has all been done before.
The June 26, Inquirer article did mention, somewhat as an aside:
Hahnemann, which traces its roots to a homeopathic medical college opened in 1848, has been through a tumultuous era dating to at least 1993, when Allegheny Health, Education, and Research Foundation acquired it as part of rapid expansion that led in 1998 to what was then the nation’s largest nonprofit health-care bankruptcy.
Tenet Healthcare Corp. bought Hahnemann and eight other Allegheny hospitals in the Philadelphia region but quickly scaled back, hanging on to just Hahnemann and St. Christopher’s, which were frequently the subject of sales negotiations that failed until Freedman decided to leap across the country from his Southern California base.
The Freedman to which this refers is one Joel Freedman, president and founder of American Academic Health Systems LLC, the last for-profit firm to own the hospital.
So Hahnemann and one other hospital were already the only survivors of the eight hospitals Tenet bought in 1998? I could find a 2017 article that stated that all other hospitals it owned in Philadelphai were either sold or closed by then. One hospital it sold, the Graduate Hospital, was converted into a long term care facility (look here). The fate of the other six hospitals seems anechoic.
However, the lassitude greeting the demise of the last remaining hospitals was foreshadowed by the story of Tenet's precursor in the Philadelphia "market," the Allegheny Health, Education and Research Foundation (AHERF) whose demise has been much discussed on our humble blog as a harbinger of the dysfunction that would afflict US health care.
As we noted
in 2008 (and discussed most recently in 2013 here), although the AHERF bankruptcy appears to be the largest
failure of a not-for-profit health care corporation in US history, its
story has produced remarkably few echoes for doctors, other health care
professionals, health care researchers, and health policy makers. I
often use the fall of AHERF as major example in talks, at least the few
talks I am allowed to give on such unpleasant subjects. Rarely have more
than a few people in the audience heard of AHERF prior to my discussion
of it. I only could locate one article in
a medical or health care journal that discussed the case in detail,
albeit incompletely since it was written before Abdelhak's guilty plea
[Burns LR, Cacciamani J, Clement J, Aquino W. The fall of the house of
AHERF: the Allegheny bankruptcy. Health Aff (Millwood) 2000; 19: 7-41.] I
doubt the case is used for teaching in most medical or public health
schools. The lack of discussion of such a significant case is
a prime example of the anechoic effect.
Some of the important points of this case will sound familiar (see also this narrative, starting on page 5):
AHERF, one of the largest health care systems of its day, was
built by the poster-boy for health care imperial CEOs, Sherif Abdelhak.
Abdelhak, who started as food services purchasing manager at Allegeheny General Hospital, was repeatedly hailed as a "visionary" (in the March, 1997, ACP Observer)
a "genius," and the like. His plans to create a huge integrated health
care system were part of the wave of the future. Abdelhak was even
invited to give the prestigious John D Cooper lecture at the annual
meeting of the American Association of Medical Colleges (AAMC), which
was published in Academic Medicine [Abdelhak SS. How one academic health
center is successfully facing the future. Acad Med 1996; 71: 329-336.]
He proclaimed that "we will need to create new forms of organization
that are more flexible, more adaptive, and more agile than ever before."
And he announced that "my aim as chief executive has been to unleash
the creativity and productive potential of every individual and to
provide an environment that encourages teamwork"
While Abdelhak was making these grandiose promises, he paid himself
and his associates very well. For example, he received $1.2 million in
the mid-1990s, more than three times the average then for a hospital
system CEO. He lived in a hospital supplied mansion worth almost
$900,000 in 1989. Five of AHERF's top executives were in the top 10 best
paid hospital executives in Philadelphia.
As AHERF was hemorrhaging money, Abdelhak continued to pay himself and his cronies lavishly.
After the AHERF bankruptcy, which was at the time the second largest
bankruptcy recorded in the US, Abdelhak was charged with numerous
felonies involving receiving charitable assets. In a plea bargain, he pleaded no contest to misusing charitable funds, a misdemeanor, and was sentenced to more than 11 months in county prison.
Note that at its peak, AHERF had 14 hospital in its network. After its bankrupcy, it transferred 8 hospitals, including Hahnemann and the Medical College of Pennsylvania teaching hospital to Tenet. In 2003 Tenet closed MCP (look here). Tenet is a for-profit hospital system with its own history of bad behavior (look here). So out of a 14 hospital network ultimately only one, not Hahnemann apparently will survive.
However, few people, even in Philadelphia seem to remember that history, and therefore seem to have drawn lessons from it. However, had they, perhaps they would have concluded, as we asserted in 2013,
The story of AHERF is not merely that of an unlucky bankruptcy. It shows
what can go wrong when health care is taken over by generic managers who adapt the latest management fads, and health care decision making is ruled by marketing, public relations and propaganda instead of evidence and logic, and allows power to be concentrated in organizations run by imperial CEOs. We did not get a chance to learn this history, so we seem bound to repeat it.
Saving health care will take clear thinking and hard work by a lot of
people. The "visionaries," if we let them, are likely to depart with a
huge cache of money, leaving us and health care worse off. If it is just
"not done" to talk about cases such as that of AHERF, and other
examples of "recent unpleasantness," how will be learn not to fall for
the propaganda?
Of course, it is those who benefit from the propaganda who do not want us catching on to their game.
If physicians, health professionals, health care researchers, and health
policy makers do not learn the lessons of the fall of AHERF, and now the fall of one of its two surviving hospital components, they will
be doomed to see its endless repetitions, throughout the land.
With apologies to the Bare Naked Ladies - "it's all been done before"
Health Care Corporations Promote Their Social Responsibility
The US health care system's extreme dsyfnctionality is now a cliche. So it's no wonder that everyone seems to want to make things better. Big health care corporations in particular tout their socially responsible ideas for health care reform.
For example, PhRMA, the trade organization for drug and biotechnology firms, describes its mission thus:
PhRMA is committed to advancing public policies in the United States and around the world that support innovative medical research, yield progress for patients today and provide hope for the treatments and cures of tomorrow.
Amgen states simply its mission is "to serve patients."
our commitment [is] to positively impact our communities, to inspire the next generation of scientists, to solve social and environmental challenges and to create a diverse and inclusive workforce that thrives professionally and personally.
Giant pharmaceutical/ biotechnology/ device company Johnson & Johnson has its famous "credo" which starts with
We believe our first responsibility is to the doctors, nurses and patients, to mothers and fathers and all others who use our products and services.
Furthermore,
We are responsible to the communities in which we live and work and to the world community as well. We must be good citizens – support good works and charities and bear our fair share of taxes. We must encourage civic improvements and better health and education.
With all that positivity supporting better health care, one would think that health care dysfunction should be soon gone. But maybe under all this talk about corporate responsibility lies something darker.
An Early Case of Dark Money in Health Care
Back in 2012 we discussed a case of "dark money" being used to conceal sources of support for particular health policy and political positions. The case was of the Center for Protection of Patient Rights, an obscure group whose mission was to "protect the rights of patients to choose and use medical care providers." The CPPR financed the US Health Freedom Coalition, led by Dr Eric Novack, which received nearly its entire budget —
$1.7 million — from the center to help pass a state ballot measure that
aimed to block President Obama's healthcare overhaul. The Center ultimately transferred $55 million to Republican candidates in the 2010 election. Its money came from the equally obscure Americans for Job Security, and was conveyed by groups such as the American Future Fund. The people who gave the money to the Americans for Job Security remained unknown, save for one wealthy Alaskan "landowner."
Do Health Care Corporations Put Their Money Where Their Mouths Are?
This year, we discussed the case of huge pharmacy chain CVS,which proclaims its "social responsibility," and its policy of only making charitable contributions to improve "health and healthcare nationwide." Yet CVS was donating to America First Policies, a supposed non-profit group devoted to promoting the partisan agenda of President Trump, including "repealing and replacing Obamacare," and immigration policies such as building the "wall" and deporting "illegal immigrants." America First Policies appears to be yet another dark money organization. CVS only decided to stop contributing when journalists revealed that America First Policies staffer had made flagrantly racist and pro-Nazi comments.
This suggested that it is possible that health care corporations which promote themselves as socially responsible and non-partisan may actually be secretly promoting political agendas that might shock some of their consumers and/or patients, employees, and health care professionals who must deal with them.
We have now found some more cases that reinforce this suspicion, showing how pharmaceutical and biotechnology companies have funneled funds through more "dark money" organizations to support policies that do not fit so well with the image they want to convey.
The PhRMA Backed Dark Money Campaign Against an Ohio Initiative to Control Drug Pricing
In August, 2017, the International Business Times revealed how the pharmaceutical/ biotchnology industry had set out to defeat a 2017 Ohio initiative meant to hold down drug prices without revealing who was funding it.
PhRMA had already succesfully defeated a similar initiative in California in 2016. However, industry support for this campaign, while obscure, was not a secret.
PhRMA set up ... Californians Against the Misleading Rx Ballot Measure, which raised over $111 million for its campaign against a California initiative that ... would have blocked that state from paying higher drug prices than those negotiated by the Veterans Affairs Department. The trade group set up a political action committee in California to which pharma companies donated directly— so PhRMA had to disclose these donors. Merck, Pfizer and Johnson & Johnson gave over $9 million each; Amgen gave $7.6 million; and 19 other drug companies gave $1 million or more. The PhRMA-run committee spent nearly all of the millions it raised, and the measure failed to pass, with 53 percent of voters shooting it down. All donors except for Genentech and Gilead Sciences are PhRMA members, and only a handful of companies out of more than 30 total corporate donors are headquartered in California.
Somehow, with all the news coming out about the 2016 US elections, this generated little interest. However, in Ohio in 2017, PhRMA was able to do something similar while keeping the corporate sources of the money hidden. Their target was:
Issue 2, the Ohio Drug Price Relief Act — a citizen-initiated ballot measure designed to prevent state agencies, including the state Department of Medicaid, from purchasing drugs at rates any higher than the lowest amount paid by the federal Department of Veterans Affairs, which negotiates with drug companies and saves between 20 and 24 percent on drug costs.
This time:
Pharmaceutical Research and Manufacturers of America (PhRMA), the biggest trade organization in the U.S. representing major drug companies, created a political action committee on May 1 called Ohioans Against the Deceptive Rx Ballot Issue. On the same day, PhRMA also founded a limited liability corporation of the same name and registered at the same address; under normal circumstances, it would not be required to disclose its donors. Campaign finance reports document only one donor to the ballot measure committee: the linked LLC.
So contributions from corporate donors to the LLC to financeed the political action committee were concealed. So,
'Certainly, setting up an LLC to launder drug company money into fighting the ballot measure looks like an effort to evade Ohio's transparency and disclosure laws,' Brendan Fischer, director of federal and Federal Election Commission reform at the nonpartisan Campaign Legal Center, told International Business Times in an email.
Also,
The Campaign Legal Center contends that hiding donors this way at the federal level violates the Federal Elections Campaign Act, which prohibits 'straw donors.'
There were only two flies in the ointment. Two companies did disclose donations to the LLC:
According to the Columbus Dispatch, California-based Amgen gave $6.3 million from 2016 through June 2017, and Biogen, headquartered in Massachusetts, gave $1.5 million last year. This accounts for roughly half of the $15.8 million total that PhRMA’s LLC raised in just May and June to fight Issue 2.
Who donated the rest, amounting to some $58 million, remains unknown. And the effort to defeat Issue 2 was succesful, as reported by Cleveland.com in November, 2017.
Issue 2 also now holds the distinction of being the most expensive ballot issue in state history, with more than $74 million raised over the course of three years, topping the $64.4 million spent on Issue 6 in 2008, which sought permission for a casino in Wilmington, Ohio. Issue 6 also failed at the ballot.
Big Pharma accounted for more than $58 million of the total raised.
Furthermore,
Because the drug companies passed the money through a limited liability company created with the intention of funneling cash to the opposition campaign, it's currently impossible to tell which companies actively spent money combating the initiative in Ohio.
A proponent of Issue 2 charged:
'The onslaught, the bombardment of television advertising that was misleading, lying and negative led to tremendous confusion,' he said.
Uncertainty from the public about the effects of the bill coupled with the ugliness of the campaign likely led to Issue 2's defeat. Voters were often confused and felt both sides were of zero help in explaining the issue.
Think of the campaign to defeat Issue 2 as a proof of the concept that health care corporations can finance campaigns against policy measures using dark money organizations to hide their support.
But no one would be surprised to find out that pharmaceutical companies were against a policy measure that would restrict the prices they charge. Our next case shows how the dark money ruse can be used by corporations to support partisan policies that conflict with their proclaimed social responsibility and non-partisan nature.
The PhRMA Backed Dark Money Campaign to "Repeal and Replace" the Affordable Care Act (ACA)
Investigative journalism from Kaiser Health News appeared in the New York Times and the Washington Post in late July, 2018 showing how PhRMA again used dark money, but this time to advocate for "repealing and replacing" the Affordable Care Act (known informally as "Obamacare"), which PhRMA had previously supported, and about which it was then ostensibly neutral. The article began,
In 2010, before the Affordable Care Act was passed by Congress, the pharmaceutical industry’s top lobbying group was a very public supporter of the measure. It even helped fund a multimillion-dollar TV ad campaign backing passage of the law.
But last year, when Republicans mounted an aggressive effort to repeal the law, the group made a point of staying outside the fray. 'We’ve not taken a position,' Stephen Ubl, head of the organization, the Pharmaceutical Research and Manufacturers of America, known as PhRMA, said in an interview in March 2017.
This was deceptive.
That stance, however, was at odds with its financial support of another group, the American Action Network, which was heavily involved in the effort to repeal the act, often referred to as Obamacare. The network spent an estimated $10 million on an ad campaign designed to build voter support for its elimination.
'Urge him to repeal and replace the Affordable Care Act now,' one ad running in early 2017 advised viewers to tell their congressman. That and similar material (including robocalls) paid for by the American Action Network ran numerous times last year in 75 congressional districts.
PhRMA was one of AAN’s biggest donors the previous year, giving it $6.1 million, federal regulatory filings show. And PhRMA had a substantial interest in the outcome of the repeal efforts. Among other actions, the Republican-backed health bill would have eliminated a fee the companies pay the federal government, one estimated at $28 billion over a decade.
But there was no way the public could have known at the time about PhRMA’s support of the network or the identity of other deep-pocketed financiers behind the group.
The KHN report went on to explain how this works
Unlike groups receiving its funds, PhRMA and similar nonprofits must report the grants in their own Internal Revenue Service filings. But the disclosures don’t occur until months or sometimes more than a year after the donation.
The conservative-leaning AAN has become one of the most prominent nonprofits for routing what is known as dark money — difficult-to-trace funds behind TV ads, phone calls, grass-roots organizing and other investments used to influence politics. Such groups have thrived since the Supreme Court’s Citizens United decision in 2010, which loosened rules for corporate political spending, and amid what critics say is nonexistent policing of remaining rules by the I.R.S.
Generally speaking, dark-money groups are politically active organizations, often nonprofit, that, under I.R.S. regulations, are not required to disclose the identities of their donors.
Such groups are often chartered under Section 501(c)(4) of the tax law, which grants a tax exemption to 'social welfare organizations.' For those seeking to influence politics but stay in the background, 501(c)(4) designations offer two big advantages: tax exemption and no requirement to disclose donors.
The AAN seems to be an obviously partisan, right-wing, pro-Republican group.
PhRMA’s $6.1 million, unrestricted donation to AAN was its single-biggest grant in 2016, dwarfing its $130,000 contribution to the same group the year before. Closely associated with House Republicans — AAN has a former Republican senator and two former Republican House members on its board — the group backed the failed G.O.P. health bill intended to replace the Affordable Care Act. It also supported the successful Tax Cuts and Jobs Act of 2017, which reduced corporate taxes by hundreds of billions of dollars over a decade.
So far in this election cycle, AAN has given more than $19 million to the Congressional Leadership Fund, a Republican super PAC with which it shares an address and staff, according to the Center for Responsive Politics. The fund recently ran ads opposing Democratic candidates in high-profile special congressional elections in Georgia and Pennsylvania.
In fact, PhRMA made a variety of contributions to dark money groups associated with right-wing and/or Republican party backed causes, while it presumably maintained a non-partisan public stance.
PhRMA gave nearly $10 million in 2016 to politically active groups, including AAN, that do not have to disclose donors, its most recent filing with the I.R.S. shows. By contrast, PhRMA and its political action committee made only about $1 million in political donations in 2015 and 2016 that were disclosed to regulators and reported by the Center for Responsive Politics.
PhRMA’s 2016 political activities included support for the Republican National Convention. Rather than directly support the Cleveland convention, which several companies pulled out of after it became clear that Mr. Trump was going to be the nominee, PhRMA routed $150,000 through limited liability companies with names like Convention Services 2016 and Friends of the House 2016.
Like 501(c)(4)s, LLCs do not have to disclose their donors. PhRMA’s support was revealed in I.R.S. filings more than a year later. (Donations by PhRMA and other groups to Friends of the House, which financed a luxury lounge for convention dignitaries, were first reported by the Center for Public Integrity last fall.)
PhRMA’s surge in donations to AAN coincides with the arrival of Mr. Ubl, who took over as president and chief executive in 2015 and has longstanding ties to Norm Coleman, a former United States senator from Minnesota who is now the network’s chairman. Mr. Ubl once ran the lobby for manufacturers of knee implants, heart stents and other medical devices, one of which, Medtronic, is based in Minneapolis.
Also,
PhRMA’s 2016 dark-money contributions included $150,000 to Americans for Prosperity, a conservative group associated with the billionaires Charles and David Koch. Their group has already signaled it will be active in November’s elections, running attack ads against Senator Jon Tester, a vulnerable Montana Democrat, for not supporting a repeal of the Affordable Care Act.
PhRMA also gave $50,000 to Americans for Tax Reform, run by the conservative anti-tax activist Grover Norquist.
In contrast, PhRMA gave lesser amounts to groups identified as centrist or left-leaning.
Mostly smaller amounts went to centrist and liberal groups. Center Forward, which claims to seek bipartisan, common ground on drug policy and other issues, received $300,000 directly from PhRMA and another $179,000 from a PhRMA-backed group called the Campaign for Medical Discovery, according to tax filings.
And the groups to which they donated were also pursuing narrower issues that supported the industry's economic interests, not broadly partisan (and in this case, prro-Democratic) issues. For example,
Center Forward worked to preserve a tax credit for researching rare-disease medicines known as orphan drugs. PhRMA took a similar stance, encouraging Congress “to maintain incentives” for rare-disease drugs.
The KHN article noted that there is evidence that individaul pharmaceutical companies hide their political advocacy, possibly mainly their advocacy of right-wing and/or Republican backed causes, in similar ways.
Johnson & Johnson gave $35,000 that year to the Republican Main Street Partnership, a 501(c)(4) that describes itself as a coalition of lawmakers committed to 'conservative, pragmatic government,' the C.P.A. data shows.
But the center’s research also shows that many pharmaceutical companies don’t disclose donations made to 501(c)(4) organizations, nor are they legally required to do so.
Corporations 'could dump millions into one of these (c)(4)s and nobody would ever know where it came from,' said Steven Billet, a former AT&T lobbyist who teaches political action committee management at George Washington University.
Summary and Discussion
So in three cases, health care corporations, and/or their trade associations, made significant financial contributions to dark money organizations, thus avoiding reporting of such fund transfers. In two cases, these fund transfers went to organizations with clearly partisan, right-wing, pro-Republican and/or pro-Trump agendas. Yet the corporations and their trade association had publicly committed themselves to social responsibility, putting patients and health care ahead of all other concerns, and had never advertised themselves as partisan, explicitly politically conservative, and/or Republican.
This is a new dimension of stealth health policy advocacy or stealth lobbying. Most of the previous, at least pre-2016 campaign, examples we had found of these involved corporations promoting measures that would improve their revenue (and consequently their top managements' pay). They did not involve explicitly siding with a single political party or political philosophy.
Patients, consumers, health care professionals, and the public at large might not be pleased but would probably not be too suprised that health care corporations and their management pursue financial self-interest, but prefer doing so without much publicity. However, I suspect most people would be unpleanatly shocked to find out that well-known health care corporations have been actively siding with a single political party and that party's ostensible political philosophy, but keeping that support very quiet.
Since such dark money support is by definition secret, who knows how many health care organizations have been doing this?
As an aside, I wonder if this hidden support from large corporations has pushed one political party to more extreme actions despite such actions' popular disfavor? But that is for more politically attuned people to ponder.
In any case, as we have said again and again,...
There are myriad ways corporate and
political insiders push health policy agendas because of self-interest,
regardless of their effects on patients' and the public's health.
Health policy in the US has become an insiders' game. Unless it is
redirected to reflect patients' and the public's health, facilitated by
the knowledge of unbiased clinical and policy experts rather than
corporate public relations, expect our efforts at health care reform to
just increase health care dysfunction.
Physicians, public health advocates, whatever unbiased health policy
experts remain must educate the public about how health policy has been
turned into a corporate sandbox. We must try to somehow activate the
public to call for health care policy of the people, by the people, and
for the people.
